Thursday, April 9, 2009

Osteoporosis: Beyond Boniva to Integration

What is bone? It’s a living, active tissue composed of vitamins, minerals and other substances, from calcium, magnesium, boron, strontium, to a protein matrix that attracts calcium and other minerals. We build bone density (or amount of mineral) until age 35 and then it gradually decreases with age with some acceleration in women at the time of menopause due to decreased hormones.

The purpose of this blog entry is to review an integrative approach to the health of your bones, drawing upon nutritional healing and the benefits of movement, the role of pollutants and xenohormones, as well as new information, made available just in the past couple of years, about the benefits of minerals such as strontium and “quarter-dose” natural estrogen in improving bone density and reducing fracture.

Osteoporosis, or porous bone, is a disease of low bone density and structural deterioration of bone tissue, leading to bone fragility and an increased risk of fractures, particularly of the hip, spine and wrist. In most cases, calcium and other minerals leeches out of our system, leading to bones getting thinner and more porous, like Swiss cheese. Women are more affected than men by a 6:1 ratio. Half of Americans over 50 have osteoporosis, which became an epidemic in 1950. Yet since 1950, the rate of fracture has doubled in the U.S. and now millions of fractures occur annually. Why? Some postulate that something has happened in our environment, and the leading suspect is the depleted soil used for most farming. As we’ve used less composting and manure in soil, there is less trace minerals available in our food supply such as zinc, copper, strontium, manganese and silicon. Reinvigorate your commitment to composting, and use it in your garden, as a way of improving your bones!What are some of the modifiable and non-modifiable risk factors? The main risk factors are Caucasian race, female gender, menopause (especially early), weight less than 127 (fat makes hormones, and thinner women have less); smoking, family history and personal history of fracture. Most of these risk factors you cannot change. Others you can, including low bone density and sedentary lifestyle. Caffeine drinkers and high-glycemic carbohydrate addicts also have an increased risk, and after 2 cups of coffee or sugar, increased calcium is lost through the urine for several hours.

One other risk factor that is not well-known is endogenous estradiol level, or the level of estrogen made naturally by your body. We know in post-menopausal women from a study at UCSF that if you are in the lowest quartile, you have the highest risk of osteoporosis. This makes intuitive sense. On the flip side, women with the highest quartile of endogenous estradiol have the highest risk of breast cancer. This is in women not on hormone therapy, synthetic nor bioidenticals. It seems as usual that the middle road might be best in terms of reducing risk of either osteoporosis or breast cancer, which is where the new quarter-dose estrogen comes in.

We know from the Women’s Health Initiative that you can reduce your risk of hip and vertebral fracture by taking hormone therapy for 5 years. Yet many women do not want to accept the small risk of other problems such as breast cancer in 1.9% (versus 1.5% in women on placebo pills), stroke in 1.5% (versus 1.1%) and heart attack in 1.9% (versus 1.5%).Since WHI, millions of women have stopped hormone therapy since the synthetic hormones do more harm than good. Many women found they could not tolerate the poor quality of life associated with the increased hot flashes, night sweats, joint aches and poor mood, and restarted at half-doses.

The half dose has fewer risks and is almost as effective at reducing symptoms. How low can we go? There is a new natural estrogen patch being tested now that is a quarter of the standard dose, and it has been shown in the best quality study design (randomized controlled trials) to improve the hip bone density by 1% and the spine bone density by 2-3% in just 2 years, with very few risks. We should be hearing more about this in the future, but it may be a great option for thinner women with low endogenous estradiol levels. Other women find that the quarter dose isn’t enough when they’re suffering from hot flashes, poor sleep and mood, and choose a more physiological dose of bioidentical hormones, which are hormones identical to what your body made in your 20s and 30s.

I was trained in OB/GYN residency to hand out Fosamax like Halloween candy to my postmenopausal women with low bone density. Now we have Sally Field telling us to take Boniva instead, since it’s just once/month. Unfortunately bis-phosphonates, like Boniva, Actinel and Fosamax, are toxic and have serious risks from hurting your gastrointestinal system to the more serious osteonecrosis of the jaw. Wouldn’t it be better to approach osteoporosis more from a nutritional perspective, with the idea of using therapies that occur naturally in the body such as mineral therapy?

There are several nutritional deficiencies that increase your risk of osteoporosis. We all know that calcium deficiency is one risk. Yet many women do not realize that their gluten sensitivity, or other cause of bowel inflammation such as food allergies, is interfering with their ability to absorb calcium from their diet.

Women with Celiac disease have an increased risk of osteoporosis and need special care to get sufficient calcium. Vitamin D deficiency is another common cause, especially with our more religious use of sunblock. Magnesium deficiency is also very common and can be associated with fatigue, anxiety, insomnia, migraines, muscle aches as well as osteoporosis. In one study, 84% of women with osteoporosis had magnesium deficiency and most of us don’t get enough from our diet. We have seen in some research studies increased bone density of up to 8% in women supplemented with magnesium. Manganese deficiency is another risk factor and affected famed NBA player Bill Walton until a holistic physician figured out it was the cause of his repetitive fractures that threatened his career. You can get your levels checked for all of these minerals. Another important issue is something Dr. Alan Gaby calls the “homocysteine connection,” which is the increased homocysteine levels we see if some people who have excessive animal protein consumption. Homocysteine levels can also be correlated with heart disease and it is important to know your level.

Heavy metals can also be associated with osteoporosis, including the ubiquitous toxin aluminum. Aluminum is added to some municipal water supplies as a way of reducing particulate matter. Aluminum cans containing beer have three times the amount of aluminum as glass bottles, and for cola, it’s six times! Other risky heavy metals are lead and tin, especially from water pipes and tin cans containing food. Consider getting your levels checked also for heavy metal toxicity if you find yourself with low bone mass.

One promising new approach is to supplement with strontium, which is a natural therapy. Strontium is licensed in Europe but has not yet been approved in the U. S. by the FDA. There are several studies showing that it increases bone density and reduces fracture in women, even in older women over aged 74. One study in particular, published in the New England Journal of Medicine in 2004 showed that in 1649 women aged 50+ who had at least one vertebral fracture, strontium ranelate led to fewer vertebral fractures and increased bone density. Women in the placebo group lost bone density. The dose used in Europe is 2 grams taken at bedtime more than 2 hours after eating or drinking anything other than water. Stontium ranelate is not yet approved for use in the U.S. as it is still under investigation.Exercise is another important strategy. All exercise is good,e.g. swimming is better than no exercise in terms of your bones and muscles, but some forms are better than other. Most research shows that a combination of impact aerobic exercise such as walking or running, along with resistance training and/or yoga can increase bone density up to 1% per year.

We all know by now that we should take care to get a total of 1200 mg of calcium from our diet and/or supplements combined with 600-800 IU Vitamin D. Many people reach for their Tums, but take care to get a calcium supplement without aluminum in it. In summary, there are nutritional and lifestyle interventions that can help you prevent and reverse osteoporosis.If you have osteoporosis, I recommend that you get your Vitamin D, homocysteine, magnesium and manganese levels checked. Supplement if you are low. Optimize your exercise regimen and take care not to ingest heavy metals such as aluminum, lead and tin. Consider bioidentical hormone therapy if appropriate and in consultation with a trusted physician. Consider quarter dose estrogen if your endogenous estrogen is low. Keep an eye out for emerging data on strontium.

About Me

I'm an organic gynecologist, yoga teacher + writer. I earn a living partnering with women to get them vital and self-realized again. We're born that way, but often fall off the path. Let's take your lousy mood and fatigue, and transform it into something sacred and useful.

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Sara Gottfried, MD

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